MDNews - Central New York

Payer Contracts By Jonelle Todd Do you revie w every clau se of your payer cont racts befo re comm itting , or Do you simply sign them with out givin g it much thou ght? Know exac tly what you are getting into befo re signi ng on the Dott eD line. P AYER-PROVIDER CONTRACTS ARE crucial to being compensated for your work, but the insurance company does not hold all the power. Do your homework, and you will have a better chance of cutting a deal that is in your favor. Diagnosis: Problem Payer Start by taking a good look at the big picture: Which insurance companies make your contractual obligation worth your while, and which barely cover (or do not even come close to meeting) your costs? Once you know this, you can focus on rectifying the contracts that are not working in your favor. Healthcare consultant Jeffrey B. Milburn, MBA, CMPE, writing for Modern Physician, recommends you calculate how much each insurer has paid you per visit during the past year. For each insurer, divide the total revenue by total visits; this will produce an 22 | Central New York MD News ■ MDNEwS.COM average dollar figure for each patient. Repeat this step for each insurance company, and compare the results. The companies whose compensation is below par should catch your eye right away. Payment per patient is the first — but not the only — factor to consider. For instance, a particular insurance carrier's payment levels may appear to be in line with all the others, but the company may be responsible for most of the administrative headaches — such as denials, subsequent appeals paperwork and lost claims — that inconvenience your office staff and patients alike. Decipher the Lingo When you review a payer contract, be sure you fully comprehend the contract language. Understanding how the company defines important terms and spells out key provisions is vital to structuring an agreement both parties can live with. Charles E. Rhoades, MD, writing for the American Academy of Orthopaedic Surgeons online practice management center, urges physicians to examine the wording of terms relating to payments and covered services. One of the most common terms that can produce grief is "usual and customary" — the fee on which a company bases payments. Does this mean the amount you normally charge for service? Or the average fee charged by other practices in your area? Or a figure generated by another organization? If in doubt, ask. Be aware of amendment provisions, which usually state that you agree to abide by any changes to the company's rules and regulations, but do not spell out the carrier's obligation to inform you of these changes. Make sure that your written consent is required for amendments to the agreement, that you will be notified within a certain time frame, that the notification will be sent with proof of delivery, and that the

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